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FEATURE

are calculated. They calculate an ‘average’ death rate for a certain and he goes home to the third floor of a rooming house with no
procedure (CABG, heart valve etc) then score individual surgeons elevator. Guess which doc gets one star and who gets the fiver?
against this statistical mean. They insist that their programs even Here’s another trait that the almighty computer cannot account
out the inconsistencies of age, the complexity of the operation, co- for. Two surgeons may be technically of similar competence but
existing medical conditions, previous similar surgeries, risk factors one is timid, unsure of himself, or diagnostically challenged.
such as smoking etc. (but they don’t say how they do this). Listen Here’s the scenario: The patient has severe 5-level lumbar disc dis-
to this statement on their website: “There is reason to believe that ease and presents to the above surgeon. Being, younger and less
a surgeon can affect 90-day outcomes by doing better work during experienced, the surgeon chooses to perform a thirty minute
the surgery itself, by making sure the hospital provides high quality laminectomy at the two worst levels. The patient leaves hospital
and safe care, by following up with the patient and the patients’ the next day, has zero complications, and doesn’t die. His surgeon
other providers after the patient’s hospital release, and by helping scores a big, fat 5-star rating. Here’s the catch: the patient doesn’t
to ensure that the patient is released to a safe and supportive envi- get better because the operation he needed was a five-level fusion.
ronment.” Now that’s a lot of responsibility on one pair of shoul- A year later the patient sees another, more experienced surgeon
ders. So, I suppose the schoolteacher is responsible for the cafeteria who does the correct operation. Because of the previous laminec-
food, toilets getting flushed, the kid getting home, doing homework, tomy, the patient gets a spinal fluid leak requiring another surgery
not fighting with his brother and being in bed by nine! and three more hospital days. When all is said and done, the fusion
Another fallacy—length of stay. Boy, did I blow it recently. One works great and the patient is happy. Again, which doc gets the
of my patients almost a year post-op developed a redness to his one and which the five?
back incision. I felt that a ten minute I&D (incision and drainage) Enough of this back and forth. What I did was put the SUR-
was appropriate. All went well until he hit recovery and went into GEONRATING.org system to the test. I looked up all the spine
pulmonary edema. He had a cardiac history, needed a new pace- surgeons they had listed in San Antonio. I’m certain not all were
maker, but was cleared for surgery by his cardiologist. Two weeks listed but it provided me with 27 names, both neurosurgeons and
in cardiac ICU and four weeks later he goes (alive and well) to rehab. orthopedic surgeons. I’ve practiced in San Antonio since 1989 so I
That’s a big, fat ‘F’ on my report card. And don’t get me started on know everyone and the kind of practice they have. I know who does
inpatient rehab. My patient undergoes a spinal fusion on Monday the big cases that most other spine surgeons avoid (in fact, many
and is ready for transfer by Thursday. On Monday a week after sur- spine surgeons refer these cases to other spine surgeons—this is a
gery we’re still waiting for insurance approval. Guess who gets phenomenon that the computer geeks don’t understand). Of the
dinged for excessive length of stay? (Hint: not the hospital, insur- 27 total spine docs, I identified seven who do the big, bad stuff on
ance company, or cafeteria food). There’s length of stay and there’s a routine basis. Don’t get me wrong, the others are great surgeons;
length of stay. Personally, I am not a special agent for hospitals or they just generally avoid the 10-hour, 12-level, re-re-do high risk
insurance companies whose job it is to get patients the heck out. If procedures. Remember I said that SURGEONRATING had a one
a patient feels the need for another day in hospital, so be it! I think star (bad surgeon) through five star (superman) rating. The average
that this component of the ‘grading’ system is merely to pressure for the seven complex guys was a 1.42 (range1-3). The average for
us to save them money. the other 20 surgeons was 3.30 (range3-5). I’m no statistician but,
The website admits that low income, the uninsured, Medicaid, as Yoda said, “significant it is”. So, what does this mean? If we be-
patients with social problems and poor family support—these issues lieve that SURGEONRATING is onto something then all seven
may contribute to length of stay, complications and readmissions. complex spine surgeons in San Antonio are incompetent (including
What they don’t get is that there are specialties, sub-specialties, and yours truly). If a complicated patient sees one of the other twenty
sub-sub-specialties; that is doctors in the same specialty may select docs, chances are they’ll be referred on to one of the seven. May as
what they do and don’t do. For instance, nearly 50% of MD’s do well head for the Mayo Clinic!!!
not accept Medicaid. This sets up the following discrepancy: sur- Here’s the bottom line. Doctors who take on the tougher cases
geon A does operation X on insured-only patients while surgeon B will score toward the lower end of the spectrum and those who do
takes all comers (including Medicaid and uninsured). The operations simpler cases will be at the top of the class. Period. These rating
are equally well done but one patient goes to rehab then home to a systems, while noble in concept, are flawed and misleading. Patients
supportive family. The other patient’s insurance won’t pay for rehab would do as well with a blindfold, dart, and the Yellow Pages.

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